Impact of 2018 CMS Physician Fee Schedule on Emergency Physicians

The 2018 Medicare physician fee schedule was released on Nov. 2, 2017, with generally good news for emergency medicine. As anticipated, there were minimal changes to the ED evaluation and management (E/M) codes, critical care, and observation service values for 2018. Table 50 of the final rule lists the estimated impact by specialty based on changes to the work, practice expense, and professional liability insurance relative value units (RVUs) for 2018. Most of the specialties listed, including emergency medicine, had an estimated impact of 0 percent of overall revenue being changed. There were a few winners, such as clinical social work (3 percent), podiatry (1 percent), and rheumatology (1 percent). The losers in 2018 were allergy/immunology (-3 percent), diagnostic testing facilities (-4 percent), and urology and vascular surgery (-1 percent). Keep in mind that rounding can play a big role in whether you are plus or minus 1 percent or end up with an estimated zero change.

Conversion Factor Increases

Physicians will see a small $0.11 increase to the Medicare payment per RVU in 2018. The Medicare Access and CHIP Reauthorization Act (MACRA) mandated a 0.5 percent increase to the conversion factor (the amount Medicare pays per RVU) for 2018. At the conclusion of 2017, the Medicare conversion factor was set at $35.8887. MACRA provides for annual conversion factor payment increases of 0.5 percent through 2019. With the application of the RVU budget neutrality adjustment and the target recapture amount related to misvalued procedures, the 0.5 percent update was decreased. As a result, the 2018 final rule published a conversion factor of $35.9996, representing a roughly $0.11 increase.

We received information suggesting that the work RVUs for emergency department visits did not appropriately reflect the full resources involved in furnishing these services. … We agree with the majority of commenters that these services may be potentially misvalued given the increased acuity of the patient population and the heterogeneity of the sites where emergency department visits are furnished. As a result, we look forward to reviewing the RUC’s recommendations regarding the appropriate valuation of these services” —2018 Medicare Physician Fee Schedule Final Rule

2018 RVUs for ED E/M Services Remain Stable

Work RVUs represent the most critical component of emergency providers’ reimbursement. For 2018, the work RVUs for emergency medicine services remain unchanged. For ED E/M services 99281–99285, the total RVUs are impacted slightly based on practice expense and professional liability insurance components and are essentially unchanged for 2018 as well (see Table 1). Importantly, the Centers for Medicare an Medicaid Services (CMS) has recommended that the Relative Value Scale Update Committee (RUC) survey and potentially revalue the work RVUs associated with the 99281–99285 codes, citing that they are potentially misvalued. This survey could take place in 2018, and updated work RVUs, if any, would likely be in effect in 2019.